FATIMA MEMORIAL HOSPITAL, SHADMAN, LAHORE

A member of Fatima Memorial System

Fatima Memorial Hospital, FMH College of Medicine and Dentistry, Saida Waheed FMH College of Nursing,
FMH College of Postgraduate Medicine, FMH Institute of Allied Health Sciences, ABNI-Community Outreach Program
UAN: +92 42 111 555 600, Fax: +92 42 7570586, Website: www.fmsystem.org , E-mail: hrd@fmsystem.org

STUDENT LEADERSHIP PROGRAM (SLP)

APPLICATION FORM
Instructions
1. SLP is open for all students of A-Levels and onwards, not only for pre-medical students
2. Please complete all sections and attach any additional information if necessary or you wish to provide
3. Your application and personal information will be kept confidential
4. Use BLOCK LETTERS throughout
5. Use black / blue ink only for filling the form
6. Incomplete form will not be accepted
Section: I (Personal Information)

Name: __________________________________________________________________________

Father’s / Mother’s Name: _________________________________________________________ Passport Size

Photograph
Father’s / Mother’s Occupation_____________________________________________________

Gender: Male Female Nationality: ________________

- - Date of Birth:

Permanent Address: __________________________________________________________________________________

Land Line No.: __________________ Mobile Phone: _____________________________________

Present Address: __________________________________________________________________________________

Contact: ____________________________E-Mail: _______________________________________

In case of emergency person to be contacted:

Name: _________________________Relationship: ___________Contact#________________________

Mailing Address:
_______________________________________________________________________________________

Section: II (Academic Record / Achievements)

Current Class: ______________________Current School/College/University______________________________

Marks Total Grade /

Qualification Name of Institution Year Major Subject
Obtained Marks Division

If you have any academic / non academic achievements, awards or honors, please provide details below:
 Sr.
Award / Achievement / Honor Subject / Field Year Class Institution
#:

1.

2.

3.

Section: III (Please mark your desired profession):

If your choice is medical profession please specify from the following:

MBBS BDS Allied Health Sciences

Any other ____________________________________________________________________________

If your choice is non-medical profession please specify from the following:

MBA Engineering IT Accounts Art & Design

Any other ____________________________________________________________________________

Section: IV (Previous Internship Detail)

Have you attended internship at Fatima Memorial System? Yes No

If you have attended internship at any other institution, Please provide details below

Sr. Duration
Organization / Institution Year Session Specialty
# From To
1.
2.
3.

Section: V (References)
How did you find out about internship at FMH?

Through your Institution through a friend through our web-site

Any Other__________________________________________________________________________________

Section: VI (Your Talents)

At the end of Internship we arrange a closing ceremony, please specify your talents which we can utilize at that occasion:
Please check all that applies:

Musical Instrument (specify) ___________________ Organizing

Drama / Acting Stage Decoration
Photography Script Writing
Video Capturing Make Up
 Compering Art Work / Painting
Singing Any Other__________________

Section: VII (The Schedule)

To be filled by students enrolled in A-Levels/Intermediate/American High School Diploma Students

2 Weeks 3 Weeks

Internship is available in modules of 2 & 3 weeks

2 WEEKS 3 WEEKS TIMINGS
• June 13 to June 24 (20 seats) • June 13 to July 01 (20 seats) • Monday to Friday
• June 27 to July 08 (20 seats) • July 04 to July 22 (20 seats) • 09:00am to 02:00pm
• July 11 to July 22 (20 seats) • July 25 to Aug 12 (20 seats)
• July 25 to August 05 (20 seats)

To be filled in by students enrolled in Bachelors and Masters only

4 Weeks

4 WEEKS Timings
• June 13 to July 08 (20 seats) • Monday to Friday
• July 11 to August 05 (20 seats) • 09:00am to 02:00pm

Please select one from the following

Community Work Food & Nutrition Services

Applicant’s Signature: _________________________ Date: ____________________

Signature of Parents: _________________________ Date: ____________________

Signature of Principal: _______________________ Date: ____________________

or Administrator

Section: VIII (Declaration)

I hereby declare that the statements made by me in this form are true and correct to the best of my knowledge. I understand
that I will be held liable for any material misrepresentation, omission made thereon or any other document requested by or
submitted to the Organization. I also undertake that I will abide by the rules & regulations of the Fatima Memorial System
and will not participate in any unlawful activities at FMS.

Applicant’s Signature: _______________________ Date: ____________________

Please return this form latest by May 2nd, 2011 to:

Ms. Nadia Kalsoom Mr. Naveed Mubarik

SLP Programme, 4th Floor, R#2, College Block Internship Co-ordinator
Fatima Memorial System, Shadman, Lahore-54000 Mobile: 0300-4635180
Ph: 111-555-600 Ext: 311/434 E-mail:
naveed..mubarik@fmsystem.org
E-mail: nadia.kalsoom@fmsystem.org

1. Please note while we will try to accommodate your preference, we cannot guarantee availability of seats
in your preferred time slots